Dying patients denied pain relief because of legal fears

Dying patients are being denied adequate medication to control symptoms and relive pain because nurses fear prosecution for assisting suicide, a Nursing Times survey has found.

More than one in 10 of the 2,311 respondents to the online survey of nurses said they had restricted a patient’s medication despite that exacerbating symptoms as they were concerned about being prosecuted.

The respondents acknowledged restricting medication left patients in more pain than necessary and prolonged their lives against their wishes.

Commenting on the survey, one nurse said: “I was worried about the authorities scrutinising the medication record with the intention of prosecuting me for over-medication, even though the dosage was ordered by a physician and necessary to relieve the patient’s pain and suffering.”

Another said increasing medication could be a difficult “balancing act”.

“Giving opiates could reduce pain but increase respiratory depression. I am acutely aware that my actions within my role could result in not being able to practice or legal proceedings.”

Senior nursing leaders said the survey finding showed a need for “urgent” action and clarification of nurses’ legal position and professional accountability.

Department of Health end of life care programme director Claire Henry told Nursing Times: “This is a disturbing finding. A competent and confident nurse should not approach pain relief with fear or trepidation.”

Queen’s Nursing Institute director Rosemary Cook said the Nursing and Midwifery Council code of conduct required nurses always to act in the patient’s best interest.

“Holding back on pain relief to the extent that pain is not controlled is clearly not in the patient’s best interest,” she said.

She said that nurses acting in the best interests of the patient and within the prescription made for that patient should not be prosecuted.

“But if the fear is there, and the anxiety has been planted, it is an urgent issue and [nurses] need to know where they stand,” she added.

In its manifesto published last year the National Council for Palliative Care called for mandatory training in palliative and end of life care for all healthcare professionals.

The council’s director of policy and parliamentary affairs Simon Chapman said better training would help remove myths and misunderstandings.

He said nurses needed to understand there is a “significant difference” between increasing drug doses in the relatively small increments required to control pain, and increasing them in such large doses that life is threatened or toxicity develops.

But one in three of the respondents to our survey said they did not understand the legal position of nurses with regards to assisted suicide.

Mr Chapman said: “It is very worrying to see this is preventing people from receiving adequate symptom control at the end of life. This is not acceptable and should be regarded as a failure of care.”

What survey respondents told us

“Doctors and nurses are scared to even think about this in case they are sued for overdosing the patient.”

“There is a tendency to under prescribe pain relief even among the palliative care team.”

“The fear of accusations of assisting/hastening someone’s death means that patients who are at the end of life are being denied a dignified, pain free death.”

“Although our hospital uses an end of life care pathway the doctors are very reluctant to initiate it for litigation fears.”

“As long as my motives are to relieve symptoms, and medications are administered regularly and increased gradually, I am justified in giving potentially lethal doses of medications to palliative patients. However many of my colleagues and doctors act too cautiously leaving patients in unnecessary pain, discomfort or unrest.”

“In some patients it is difficult to titrate medication to relieve symptoms effectively and not be concerned about the possibility of this accelerating the cessation of life.”

Mark Shaw, a healthcare specialist at law firm Hempsons, said the crucial fact in relation to the law was the intention with which the drug was prescribed and administered.

“If a drug has been prescribed by a doctor - and the intention is clear that it is to relieve symptoms and pain - and [the nurse] is following the doctor’s prescription by administering that medication, I don’t see any risk to the nurse,” he said.

But comments from the survey revealed nurses felt they could not always administer enough medication to control a patient’s symptoms because doctors were not prescribing adequate amounts for fear of being prosecuted themselves.

However, British Medical Association head of science and ethics Vivienne Nathanson said most doctors understood the concept of “double effect”.

“If you give a dose that might shorten life, because you are giving it to get rid of pain, that is a side effect. It is not the desired effect, so it is not criminal or unacceptable,” she said.

Nurses should alert doctors if they believed a patient was not receiving enough medication, she added.

Ms Henry agreed. She said Nursing Times’ findings “underline that nurses must work with colleagues to assess a patient’s needs on a regular basis.”

Survey results

48% of nurses have been asked to help a patient end their life

12% of nurses have restricted patient medication for fear of prosecution

33% of nurses do not understand the law on assisted suicide

Source:Nursing Times online survey of 2,311 nurses, May 2010

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Readers' comments
(23)

Anonymous | 18-May-2010 2:30 pm

“If a drug has been prescribed by a doctor - and the intention is clear that it is to relieve symptoms and pain - and [the nurse] is following the doctor’s prescription by administering that medication, I don’t see any risk to the nurse,”

Dewd I won't be coming to your firm for representation. Maybe not a problem if your working in a oncology/palliative care setting where protocols and education are in place. Definately might be a problem in a side room on an acute medical ward. I've heard a few well respected commentators claim that pain relief / sedation extend life rather than hasten it's demise, Occaisonally this happens but in my experience these drugs shorten life but improve it's quality. Maybe the professional bodies should be clearer rather than pussyfooting around the issue. It's maybe fine for a doctor to prescribe whatever, but if your the nurse administering the drug quite another.

Well actually your quite wrong about that. I know plenty of amazingly knowlegable and skilled nurses who are shockingly bad at giving adequate pain relief - probably because the culture they grew up in looks down on any opiate use.

Most people who have worked in palliative care know what the ideal is - how we get there is another story.

nurses who withhold medication prescribed for pain relief should be sacked. They lack the basic component needed to be a good nurse, compassion. If the stand over a patient who is in severe pain knowing they can relieve that pain with prescribed medications but are more concerned about their own self preservation then they are in the wrong job and do not deserve the trust placed in them to act in the patients best interest. Would you like a loved one being nursed by someone who has to think twice about relieving someone elses pain when they have the power to give prescribed pain relieving medication. Unbelievable!

There is a vast difference between giving pain medication for just symptom control and for treating those patients at their end of life. Patients that are needing just symptom control require continuous pain asssesment and probable changes to pain therapies untill the required dose, timings, and suitable drug is found for that patients condition and symptoms.Patients that are at the end of life need continuous monitoring of their pain/terminal restlessness symptoms, and it is the responsibility of health care professionals to make sure that these patients die in comfort and with dignity.That is why you will find most pain management drugs will be written up as prn administration, and frequently reviewed.When a patient is at the end stage of life, and there is nothing that will change that, then you would want that patient to die without pain or agitation which is often present at the end of life stage. In the Acute sector there appears to still be a lack of desire to both nurses and doctors in managing a patients pain control if that patient is not well controlled. Many Health Professionals still have a fear factor that they will be held accountable should they follow up a patients needs for increased Pain Control, and I can relate to that.There are now very experianced Pain Management teams in many hospitals. I would like to see more educaion from these specailist teams to work with and educate staff at ward level. Nurses and Doctors should also learn to utilise these teams as part of their patient care. Someone here, mentioned quality. So true.

Having worked in palliative and acute areas, I would not feel that I had done my job to the best of my ability if I had not kept any patient as comfortable as possible. Obviously palliative patients are deteriorating during the time that we nurse them, but I feel that it is our duty to keep them as painfree as we can (and control any other symptoms to the best level possible) by administering prescribed medication and asking for medical assessment if I am unhappy with outcome/ effectiveness of same. There is plenty of expertise available - medical staff, specialist nurses, pharmacists etc to discuss any concerns you may have. Training may also be an option. Talking to the patient (if appropriate) and the family is not only important but often helps us. I have always felt keeping a patient painfree and comfortable in their last weeks/days/hours is of the utmost importance, not just for the patient but also for their relatives. A few months ago I was one of those relatives and saw for myself the difference good nursing made. It has helped me and other family members to come to terms with our loss - knowing that the care was professional and competent as well as compassionate made a difference.Please think of the people we are doing this job for - OUR PATIENTS.

On reading this article, I am utterly amazed at how many nurses have concerns in administering medication for pain relief to palliative care patient, I work on a General High Dependency unit and therefore I don’t not come across many patients who need palliative care, however my trust uses the Liverpool care of the dying pathway. It is a pathway that is rarely used on my unit but when it is I feel happy to follow the guidelines to make my patients as comfortable as I possibly can, within this there are guidelines for the doctors prescriptions, if the doctors prescriptions are the same as the pathway guidelines then there should be no concerns in administering the medication to give the patient (and relatives) comfort why they need it most. I would assume that most hospitals follow similar pathways or have policies in place, if not why not. !!! if nurses are afraid to give medication when these guidelines and policies are in place it is obvious that more education is needed to give them confidence.

Why is it not that Nurses fear prosecution for witholding legally prescribed and legally allowed medication to relieve a dying patients pain? That to me is the crime!

I think its shocking and a gross, sickening discovery from this survey that Nurses feel so underskilled or inadequately supported to administer patients appropriate pain relief with the sole intention of alleviating the pain and suffering in a patients dying hours.

How are they worried their intention may be shown to be ending a patients life deliberately sooner? what kind of profession based on fear have we created that means that the (probably under-reported) "1 in 10" Nurses fear pain relief to the DYING in case they are prosecuted?

As for clarifying the law, this is anothe beauracratic unecessary exercise. The law is clear! Now go and give your patients as much pain relief as they need to control the pain and please please remember you can make a difference to the quaility of care of dying patients, in fact it is your duty to do so!

I am absolutely horrified at reading the results of this survey. But even more so that nurses are withholding medication because they are thinking of themselves and not the needs of their patient.Withholding medication and causing unecessary suffering to a fellow human being, in a professional capacity, is nothing short of blatant negligence.We are in the 21st century, we have the knowledge, expertise and technology to enable a patient to die in peace and with dignity.Nursing, as I am now always reading and hearing, is research based. So you nurses who completed this survey and cause unecessary suffering to your patients, may I suggest that you start doing some searches. There is a dearth of evidence to be sifted through. Take the blinkers off and look further than nursing papers. My heart goes out to your patients

i am of the opinion that if the doctor prescribes the medication and the nurse administers it to the letter,there should be no problem. it is a form of abuse to the dying patient to leave them in such pain. It is given that the medication prescribed has a double effect but in most cases there really is no choice. the level of pain these patients are in can only be treated by these particular drugs ,so there really is no choice. if you are a nurse then nurse. put yourself in the patients shoes,would you like to be in such dreadful pain just because an investigation might take place3 i think not.

Hmmm all very black and white that isnt it. Ive been on both sides..And to call for someone to be sacked in this instance is abhorrent.. you obviously havent been there. get off your high horse your not the perfect nurse either...and if you are you judgemental fool..please can you make yourself known so we can perfect ourselves too..Thankyou we'd appreciate it.

Well I wont be anonymous. It is not about being righteous. The survey has highlighted an area where further education is needed - not such a bad thing. The law can be very complex and confusing, therefore I can understand why some nurses are scared of giving pain relief to dying patients. Yes there are guidelines in place for prescribing Dr's and for nurses.

Rule of thumb is the 'reasonable man test' If in doubt, stop and think, patient is dying, is in pain, would a reasonable person (A) give pain relief to enable the patient to be painfree, thus ensuring dignity and respect and preventing any relatives present from becoming distressed OR (B) would a reasonable person withhold pain relief thus witness the patient agitated and in pain, cause extreme distress to any relatives present?? Evidence would show that a resonable person would go for option A and in a court of law the reasonable man test would be applied, hence always make sure documentation is completed, signed dated and timed.

This survey has highlighted the importance of knowledge - knowledge of pain medication, doses, how it works, contraindication, adverse affects. There are times nurses do have to question Dr's prescriptions - if in doubt, check, BNF should always be available.

I have found myself in the situation of providing relatives with information about medication being given and any potential side effects. To date all I have received is thanks, thanks for not letting their relative suffer unnecessary pain.

Just to throw the ball out into the court - I've been in situations where the family were telling me the opiates and sedation were killing the patient when I knew that the patient was being tortured without the medication. Pretty tricky situation to negiociate.

Often discussions and education with the patient, family and the nursing team are left until too late in terminal care - quite often in areas where you would expect it to have happened at the start of treatment. In acute medicine, in a side room, at 3 in the morning it's probably a little late for everyone to be on the same team.

if you're the only nurse administering the full prescibed dose, whilst the other nurses hold back, due to double effect more patients will die on your watch. how would "the reasonable man" interpret that statistic?

To the person who replied they have' been on both sides' did you mean you have been left in pain and had a nurse withhold administering pain relief to you? Or did you mean you have withheld pain relief from a person in pain even though it was prescribed.

The fact that prescribed pain relief is being withheld appears to be justified by the indignant comments. It is trivialising what is important and making whats important trivial. What's important is to relieve someones pain wherever possible. To relieve anothers pain is a vital part of caring, what's trivial is to be full of self righteous indignation but leave another fellow human being in pain.

i think its more abhorent to leave a person suffering in pain when there is pain relief prescribed that could alleviate their suffering. Not only should those who are doing it be sacked they should be prosecuted as well. It's not about being the perfect nurse it's about being a good nurse. No ifs and or buts about it.

To leave a patient with inadequate pain control is a serious breech of the code of professional conduct and in this day and age totally unnacceptable. Pain control measures have come on considerably over the years and it is inexcusable for any nurse to omit giving adequate pain control.

If you can justify your actions and have followed correct prescribing advice and your knowlege base is sound then what fear of litigation. Patients and relatives kept in ignorance are bound to be suspicious that is what you are there for to be open and discuss with them fully what the pain relief is for and why it is required. Lack of information or being kept in the dark is bound to arouse suspicion.

Stop making excuses get on and do what you are trained to do or get out of nursing.

I question the professionalism and ethics of any nurse who is able to put the needs of patients in pain and ditress after themselves and their own fears of prosecution. The needs of the patient should always be the prime concern. To withold medication and condemn your patient to a painful and undignified death is nothing short of neglect. If you find that you are the only nurse in your unit prepared to administer the correctly prescribed medication, this should be urgently discussed with your higher management. Then your dying patient can be given adequate analgesia before it is too late.